Both paper and electronic claims require the same data elements, which are based on Medi-Cal procedures.

Transcription

1 CLAIMS SUBMISSION - CMS 1500 Both paper and electronic claims require the same data elements, which are based on Medi-Cal procedures. Claims may be pended or denied when data items on claim forms are incomplete or incorrect. The following item numbers and descriptions correspond to the standard CMS 1500 Claim Form. Note: Items described as may be completed for other payers, but are not recognized by the HPSM claims processing system. Health Plan of San Mateo HCFA 1500 Submission Requirements Field Number Description Requirement 1 Medicaid/Medicare/Other ID Enter an X in the Medicaid Box 1A Insured s ID Enter Patient 9 Digit HPSM ID Number 2 Patient s Name Required 3 Patient s Birth date/sex Enter the Recipient s Date of Birth in Six- Digit Format (MMDDYY) 4 Insured s Name 5 Patient s Address/Telephone Enter Recipients Complete Address and Telephone Number 6 Patient Relationship to Insured This Field May Be Used When Billing for an Infant Using the Mother s Id by Checking the Child Box 7 Insured s Address 8 Patient Status 9 Other Insured s Name 9A 9B Other Insured s Policy or Group Number Other Insured s Policy or Group Number Updated 6/20/08 1

2 9C 9D Employer s Name or School Name Insurance Plan Name or Program Name 10 Is Patient s Condition Related To: 10A Employment 10B Auto Accident/Place 10C Other Accident 10D Reserved for Local Use Enter the amount of patient s Share-of- Cost for the procedure, service or supply. Do not enter a decimal point (.) Or dollar sign ($). (e.g. if billing for $100, enter not 100) 11 Insured s Policy Group or FECA Number 11A Insured s Date of Birth/Sex 11B 11C 11D Employer s Name or School Name Insurance Plan Name of Program Name Is There Another Health Benefit Plan? Not Required by HPSM Enter an X in the box if the recipient has other coverage. 12 Patient s or Authorized Person s Signature 13 Insured s or Authorized Persons Signature 14 Date of Current Illness, Injury or Pregnancy 15 Similar Illness 16 Date Unable to Work 17 Referring Provider Updated 6/20/08 2

3 17A ID Number of Referring Physician Enter the referring/prescribing/ordering practitioner s Medi-Cal provider # or if not amedi-cal provider enter State license number. If license number is used the full name of the practitioner must be entered in box Hospitalization Dates Enter dates of admission and discharge 19 Reserved for Local Use Use this area for procedures that require additional information, justification or and Emergency Certification Statement. See Medi-Cal Medical Services Manual for additional information. 20 Outside Lab Name is modifier 90 of Lab 21.1 Diagnosis or Nature of Illness or Injury 21.2 Diagnosis or Nature of secondary Illness or Injury 21.3 Diagnosis or Nature of tertiary Illness or Injury 21.4 Diagnosis or Nature of quartern Illness or Injury primary diagnosis, use an ICD-9-CM code secondary diagnosis, use an ICD-9-CM code number and code to the highest level of specificity for the date of service. (Do Not tertiary diagnosis, use an ICD-9-CM code quartern diagnosis, use an ICD-9-CM code 22 Medicaid Re-submission Code 23 Prior Authorization Number For physician and pediatric services requiring a Treatment Authorization Request (TAR), enter the 11-digit TAR control number. It is not necessary to attach a copy of the TAR to the claim. Recipient information on the claim must match the TAR. Only one TAR Updated 6/20/08 3

4 Control Number can cover the services billed on any one claim. 24. A. Date(s) of Service Enter the date the service was rendered in the From and To boxes in the six-digit MMDDYY, format. 24. B. Place of Service Enter code indicating were service was rendered (e.g 11= office, 21- Inpatient Hospital, etc.) 24. C. EMG Leave this box blank unless billing for emergency services. Enter and X if an Emergency Certification Statement is attached to this claim or enter in Box D Procedures, Services, or Supplies Modifier Enter the applicable procedure code (HCPCS or CPT-4 and modifier). 24E Diagnosis Code Indicate which ICD-9 code in 21 (1, 2, 3, & 4) is applicable to the service. 24F Charges In full dollar amount, enter the usual and customary fee for service(s). Do not enter a decimal point (.) or dollar sign ($). If an item is a taxable medical supply, include the applicable state and county sales tax. 24G Days or Units Enter the number of medical visits, surgical lesions, hours of detention time, units of anesthesia time, etc. 24H EPSDT Family Plan Enter code 1" or 2" if the services rendered are related to family planning (FP). Enter code 3" if the services rendered are CHDP-screening related. Leave blank if not applicable. 24I ID Qual 24J Rendering Provider ID. # Enter the rendering providers NPI and/or Legacy #. 25 Federal Tax ID Number Enter the nine digit provider Tax ID number 26 Patient s Account No. This is an optional field that will help you to easily identify a recipient on RTDs and Updated 6/20/08 4

5 EOBs. 28 Total Charge In full dollar amount, enter the total for all services. Do not enter a decimal point (.) Or dollar sign ($). 29 Amount Paid Enter the amount of payment received from the other coverage (box10d). Do Not enter Medicare payments in this box. Medicare payment amount will be calculated from the Medicare EOMB/RA when submitted with the claim. 30 Balance Due Enter the difference between Total Charges and Amount Paid 31 Provider Signature/Date 32 Service Facility Location Enter the name and address where services were rendered. 32 a NPI of the Service Facility Location Enter the NPI of the facility identified in 32 if applicable. 32 b Legacy # of the Service Facility Location Enter the Legacy number of the facility identified in 32 if applicable. 33 Billing Provider Info & Ph # Enter the name, address and telephone number of the rendering provider. 33 a Rendering Provider NPI Enter the NPI of the rendering provider if applicable. 33 b Rendering Provider Legacy # Enter the Legacy number of the rendering provider if applicable. Updated 6/20/08 5